When is it OK for children to start drinking fruit juice?

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Clinical Inquiries

When is it OK for children to start drinking fruit juice?

J Fam Pract. 2009 September;58(9):500a-500c

By

Mark B. Stephens, MD, MS LCDR MC USN

Meaghan P. Keville, BS,

Nathanael E. Hathaway, BS

Susan K. Kendall, MS (LIS)

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References

1. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States. JAMA. 2006;295:1549-1555.

2. Skinner JD, Ziegler P, Ponza M. Transitions in infants’ and toddlers’ beverage patterns. J Am Diet Assoc. 2004;104(suppl 1):s45-s50.

3. Briefel RR, Reidy K, Karwe V, et al. Feeding infants and toddlers study: improvements needed in meeting infant feeding recommendations. J Am Diet Assoc. 2004;104(suppl 1):s31-s37.

4. Dennison BA, Rockwell HL, Baker SL. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity [published correction appears in Pediatrics. 1997;100:733]. Pediatrics. 1997;99:15-22.

5. O’Neil CE, Nicklas TA. A review of the relationship between 100% fruit juice consumption and weight in children and adolescents. Am J Lifestyle Med. 2008;2:315-354.

6. Garner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.

7. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol. 2004;554:63-77.

8. Rampersaud GC, Bailey LB, Kauwell GP. National survey beverage consumption data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages. J Am Diet Assoc. 2003;103:97-100.

9. Nielsen SJ, Popkin BM. Changes in beverage intake between 1977 and 2001. Am J Prev Med. 2004;27:205-210.

10. O’Connor TM, Yang SJ, Nicklas TA. Beverage intake among preschool children and its effect on weight status. Pediatrics. 2006;118:e1010-e1018.

11. Dubois L, Farmer A, Girard M, et al. Regular sugar-sweetened beverage consumption between meals increases risk of overweight among preschool-aged children. J Am Diet Assoc. 2007;107:924-934.

12. Johnson L, Mander AP, Jones LR, et al. Is sugar-sweetened beverage consumption associated with increased fatness in children? Nutrition. 2007;23:557-563.

13. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84:274-288.

14. Sohn W, Burt BA, Sowers MR. Carbonated soft drinks and dental caries in the primary dentition. J Dent Res. 2006;85:262-266.

15. Marshall TA, Levy SM, Broffitt B, et al. Dental caries and beverage consumption in young children. Pediatrics. 2003;112:e184-e191.

16. American Academy of Family Physicians. Breastfeeding policy statement. 2007. Available at: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpolicy.html. Accessed March 25, 2008.

17. Gidding SS, Dennison BA, Birch LL, et al. Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the American Heart Association [published corrections appear in Circulation. 2005;112:2375; Circulation. 2006;113:e857]. Circulation. 2005;112:2061-2075.

18. World Health Organization. The optimal duration of exclusive breastfeeding: results of a WHO systematic review. Indian Pediatr. 2001;38:565-567.

19. US Preventive Services Task Force. Primary care interventions to promote breastfeeding: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149:560-564.

20. American Academy of Pediatrics. The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107:1210-1213.

EVIDENCE-BASED ANSWER

Children should be at least 6 months of age (strength of recommendation [SOR]: C, expert opinion) and parents should provide only 100% fruit juice in a cup (not a bottle). Intake should be limited to 4 to 6 oz a day until 12 months of age (SOR: C, expert opinion). It’s important to reiterate to parents that breastfeeding is the preferred source of infant nutrition for the first 6 (preferably 12) months of life (SOR: A, systematic reviews).

Sugar-sweetened fruit drinks have been linked to excess weight gain and obesity (SOR: B, cohort studies with mixed results). Sugar-sweetened beverages provide little nutritional benefit to children and should be restricted (SOR: C, expert opinion). See the TABLE for definitions of fruit juice, fruit drinks, and sugar-sweetened beverages.

TABLE
What’s fruit juice and what’s not

TERM	DEFINITION
Fruit juice	Beverage containing 100% fruit juice from the liquid naturally occurring in the fruit tissue; contains no artificial sweetener
Fruit drink	Beverage containing <100% natural fruit juice. Includes sweetened fruit juice reconstituted from concentrate and fruit-flavored drinks
Sugar-sweetened beverage	Fruit drinks, fruit “ades,” and carbonated beverages (including sodas and cola beverages) to which sweeteners have been added

Evidence summary

FAST TRACK

Parents giving their infants juice should give them only 100% fruit juice in a cup—not a bottle.

One of every 6 American children is overweight or at risk of becoming overweight.¹ Overweight children are more likely than normal-weight children to be overweight as adults; they’re at significant risk for morbidity and mortality from hypertension, cardiovascular disease, and diabetes in adulthood. Establishing sound nutritional habits—including appropriate consumption of fruit juices, fruit drinks, and other sugar-sweetened beverages—early in life plays an important role in preventing overweight in later childhood and adulthood.²

Fruit juice/obesity link is controversial

During the transition to table foods between 4 and 11 months of age, the top 3 nonmilk sources of carbohydrate in an infant’s diet are infant cereal, 100% juice, and bananas.² One in 5 infants routinely drinks juice before 6 months of age.³ Consuming 100% juice and fruit-flavored drinks can contribute to excess energy intake and displace other nutrient-dense foods in the child’s diet.

The role of fruit juice consumption in childhood obesity is controversial. In 1 group of 168 children 2 to 5 years of age, 9% of children who drank >12 oz of fruit juice per day were overweight, compared with 3% of those who drank <12 oz daily.⁴

A recent review of 21 studies found 6 (3 longitudinal and 3 cross-sectional) that supported a relationship between juice intake and weight and 15 (9 longitudinal and 6 cross-sectional) that suggested no link between 100% fruit juice consumption and overweight in children or adolescents.⁵

Regardless of the relationship between fruit juice and obesity, it is important to emphasize that breast milk provides essential nutrients and immune protection for the growing infant. Breast milk should remain the recommended source of nutrition through the first year of life.^6,7

Evidence-based answers from the Family Physicians Inquiries Network